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850 > Nutritional Assessment/Requirements > Flashcards

Nutritional Assessment/Requirements Flashcards

1
Q

Initial Pathway Steps

A
  1. Admission: Get height, weight, BMI
  2. Nutrition Screen within 24 hours
  3. Suspected Malnutrition?
    Yes => Nutrition Assessment
    No => Reassess in 3-7 days
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2
Q

Nutritionally-at-risk Factors

A
  • Involuntary loss of >= 10% body weight within 6 months
  • Involuntary loss of >=5% of usual body weight in 1 month
  • Involuntary loss or gain of 10 lbs within 6 months
  • BMI <18.5 or >25
  • Chronic Disease
  • Increased metabolic requirements
  • Altered diets or diet schedules
  • Inadequate nutrition intake, including no food or nutritional products for > 7 days
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3
Q

Assessment of Nutritional Status

A
  • History and clinical diagnosis
  • Physical exam/clinical signs
  • Anthropometric data
  • Labs
  • Food/nutrition intake (history, calorie counts, diet, etc.)
  • Functional assessment
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4
Q

Exam/Clinical Signs Gathered

A

Exams

  • Weight loss/gain
  • Fluid Retention
  • Loss of muscle/fat

Clinical Signs
-Inflammation: fever/hypothermia, tachycardia, hyperglycemia

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5
Q

Anthropometric Data

A
  • Weight: unintended weight loss if a validated indicator of malnutrition (measure at admission and repeat frequently)
  • Height
  • BMI: malnutrition can occur at any BMI
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6
Q

Weight Alone Problems

A
  • Doesn’t provide body composition information
  • Loss of serum proteins associated with ECF expansion
  • Concomitant diseases (CHF, ARF, Cirrhosis) associated with increased ECF
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7
Q

Labs

A
  • Markers of inflammation: elevated CRP, WBC, blood glucose levels
  • Negative nitrogen balance: sometimes support systemic inflammatory response (nitrogen from urine over 24 hours)
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8
Q

Protein and Nitrogen Balance

A
  • Nitrogen is a component of all amino acids
  • Nitrogen Balance (NB) is difference between dietary nitrogen intake and nitrogen losses
  • NB is a good marker for adequate protein intake
  • Little evidence for using NB
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9
Q

NB

A
  • NB = total protein intake (g)/6.25 - (UNN+4)
  • Positive NB: patient excretes less N than they consume (using N in new proteins)
  • Negative NB: excretes more N than they consume (use muscle as energy source)
  • May be useful to know but not common in practice
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10
Q

Food/Nutrition Intake

A

-Get information from patient or caregiver

Methods to help determine inadequate intake:

  • 24 hour recall
  • Modified diet history
  • Calorie count
  • Prior documentation of periods of inadequate food intake in medical record
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11
Q

Functional Assessment

A
  • Handgrip strength: documents decline in physical function

- Don’t use in ICU patients

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12
Q

Short Term “Simple” Undernutrition

A
  • < 72 hours
  • Glycogen rapidly depleted (insulin levels fall, glycogen levels increase)
  • FFA liberated, proteins undergo gluconeogenesis
  • Body adapts to using FFA/ketones (glucose needs decrease)
  • Metabolic rate decreases
  • Serum proteins maintained
  • Easily reversed with feeds (oral/enteral)
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13
Q

Metabolic Stress/Stress Undernutrition

A
  • > 72 hours
  • Cytokines released
  • Increased catecholamines, glucocorticoids, GH
  • Increased inflammation markers (CRP)
  • Insulin resistance associated with hyperglycemia
  • Metabolic rate increased
  • Accelerated protein catabolism (more nitrogen in urine)
  • Not reversed by simply feeding
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14
Q

Malnutrition Key Points

A
  • Nutrition imbalance leads to multiple abnormalities: inadequate intake/increased requirements, impaired absorption, altered nutrient transport and/or utilization
  • Patients may present with conditions that are inflammatory, hypercatabolic, and/or hypermetabolic
  • Can be caused by long term starvation/undernutrition, chronic diseases, or acute injuries
  • Inflammation is important factor for increasing risk of malnutrition
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15
Q

Malnutrition Evaluation

A
  • Energy/nutrition intake - % of energy requirement taken in during last week/month
  • Weight loss - % lost over period of time
  • Fluid accumulation: generalized or localized
  • Loss of body fat
  • Loss of muscle mass
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16
Q

Malnutrition Diagnosis

A
  • Severe protein-calorie malnutrition: meets at least 2 criteria from malnutrition criteria table
  • Protein-calorie malnutrition: meets 2 criteria from non-severe column OR 1 criteria from severe and 1 from non-severe
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17
Q

Clinical Consequences of Malnutrition

A
  • Decrease immune function: primary decreases in cell-mediated immunity
  • Decreased muscle function (skeletal, respiratory, cardiac)
  • Decreased wound healing (fistula formation, wound dehiscence, abscess formation, anastomotic breakdown
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18
Q

Fistula Formation

A
  • Abnormal connection that connects two organs/vessels that don’t normally connect
  • Complications: significant fluid/electrolyte/minerals/protein loss, dehydration, imbalances, malnutrition
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19
Q

Wound Dehiscence

A
  • Partial or total separation of previously approximated wound edges: failure of proper wound healing
  • Clinical significance: poor perfusion, infection risk, malnutrition
  • May require another surgery to fix
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20
Q

Physiologic Energy Needs

A
  • Energy required for all metabolic processes, growth, repair, and activity
  • Body will utilize its tissue for fuel if energy isn’t provided (catabolism)
  • Results in depletion of body cell mass and complications of malnutrition
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21
Q

BMR

A
  • Basal metabolic rate: energy required to maintain body cell mass and basal organ functions
  • Estimated with REE (resting energy expenditure) in hospitalized patients
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22
Q

Determining REE

A
  • Predictive Equations: Harris-Benedict (adjusted BW for obese), Mifflin-St. Jeor, Ireton-Hones, Penn State (ventilated patients)
  • Indirect Calorimetry (IC) - measure energy expenditure, considered gold standard for hospitalized patients, cost/availability limit use
23
Q

Harris-Benedict Equation

A
  • REE = BMR * Stress/Activity Factor
  • Activity factor varies from Sedentary to Extreme Activity
  • Units: kcal/day
24
Q

Limitations of REE Equation

A
  • No equation is more accurate than IC
  • Hundreds of equations posts, all 40-75% accurate
  • Even less accurate in obese and underweight patients
  • Poor accuracy due to non-static variables (weight, medications, body temp)
25
Q

Indirect Calorimetry

A
  • Most accurate method of determining REE
  • Measures oxygen consumption and CO2 production to calculate whole body energy catabolism over a day
  • Variables that effect the timing/accuracy of IC readings
  • Costly equipment and requires trained personnel
26
Q

IC Affecting Variables

A
  • Air leaks or chest tubes
  • Supplemental oxygen
  • Ventilator settings
  • CRRT
  • Anesthesia
  • PT and/or excessive movement
27
Q

Weight Based Equations

A
  • Recommend this or REE equation when IC not available
  • Non-obese: 25-30 kcal/day (BW)

Obese Patients

  • BMI 30-50: 11-14 kcal/kg/day (BW)
  • BMI > 50: 22-25 kcal/kg/day (IBW)
28
Q

IBW

A

Male:
106 lb for first 60 inches + 6 lbs for each inch > 60 inches

Female:
100 lbs for first 60 inches + 5 lbs each inch > 60 inches

29
Q

Enteral Nutrition

A
  • EN
  • Nutrition provided by feeding tube into GI tract
  • Not oral and NOT IV
30
Q

Physiological EN Benefits

A
  • Supports functional integrity of gut: stimulate blood flow, release of trophic agents, maintains tight junctions
  • Maintains structural integrity by maintaining villous height and supporting mass of secretory IgA-producing immunocytes in gut lymphoid tissue
31
Q

Additional Benefits of EN

A
  • Modulate stress and systemic immune response
  • Attenuate disease severity
  • Fewer complications compared to PN
  • Lower cost compared to PN
32
Q

Disadvantages of EN

A
  • Aspiration and VAP (higher risk => place postpyloric)
  • GI: diarrhea, nausea, vomiting, distension (proper rate of admin, product selection, and goal rate)
  • Complications from tube placement
  • Stigma of feeding tubes
33
Q

EN Contraindications

A
  • Small or Large intestinal obstructions
  • Paralytic ileus
  • Peritonitis
  • GI Ischemia
  • Relative and constantly changing (growing body of research on EN and outcomes)
34
Q

EN vs PN

A
  • Selecting appropriate route is key to optimize outcomes
  • EN is preferred unless there are contraindications, not tolerate after repeated attempts, unable to meet nutritional goals with EN
  • Even if on PN, initiate EN as soon as safely possible
35
Q

EN Formula Composition

A

Main components:

  • Protein: 15-20% of total calories
  • Carbs: 40-60% of total calories
  • Lipids: 25-40% of total calories
  • Electrolytes: minerals, vitamins, trace elements

-Different formulas available for special conditions (renal, hepatic, stress, diabetes)

36
Q

Standard Polymeric EN

A
  • Nutrient distribution for normal diet

- Indication: Normal GI fxn

37
Q

High Protein Polymeric EN

A
  • Protein >15% of total energy

- Indications: Catabolic states, wound healing

38
Q

Partially Hydrolyzed Oligomeric EN

A
  • “Semi-elemental”
  • Composition varies where one or more macro-nutrients are hydrolyzed
  • Indications: impaired digestion/absorption, pancreatic insufficiency, IBD
39
Q

FAA Monomeric EN

A
  • “Elemental”
  • Hydrolyzed formula, low residue
  • Indication: Crohn’s disease possible, falling out of favor in adults in favor of oligomeric EN
40
Q

Metabolism in Critically Ill

A
  • Metabolic response to stress is adaptive to survive acute illness - increase energy provision to vital tissues, altered pathways of energy production and alt. substrates needed
  • Patients at risk for stress hyperglycemia - high [glucose] increase production and/or expression of pro-inflammatory mediators
41
Q

Protein in ICU

A
  • Protein loss occurs universally in ICU (less muscle mass)
  • Magnitude of protein loss associated with increased morbidity/mortality
  • Manifestations of severe protein malnutrition: respiratory failure, immune dysfxn, poor wound healing
  • Protein most important nutrient for protecting lean body mass
  • Higher protein intake early shown to decrease mortality (opposite in overfeeding)
  • *Most important macronutrient, focus on protein if caloric requirement can’t be met**
42
Q

Enteral Protein Dosing

A

-Standard goal: 1.2-2 g/kg/day
-Burn patients: 1.5-2 g/kg/day
-CRRT/frequent HD patients: 2.5 g/kg/day (don’t restrict in renal insufficiency)
Obese
-BMI 30-40: 2g/kg/day (IBW)
-BMI >40: up to 2.5 g/kg/day (IBW)
Avoid protein restriction, especially in CRRT and liver failure pts

43
Q

EN in ICU

A
  • Start within 24-48 hours in critically ill patients who can’t maintain PO intake on their own
  • ICU patients at risk for adverse changes in gut permeability
  • Could lead to bacterial challenges, risk for systemic infection, increased risk of multiple-organ dysfxn syndrome
  • As disease status worsens, increases in gut permeability amplifies and EN more likely to favorably impact those AE
44
Q

Acute Pancreatitis Considerations

A
  • Mild acute pancreatitis: advance to PO diet as tolerated, consider EN/PN if unable to advance within 7 days
  • Mod-Severe: Place NG/OG and start trophic rate, advancing to goal as fluid volume resuscitation completed
  • Use polymeric formula when initiating early EN
  • EN>PN in severe pancreatitis (except necrotizing pancreatitis), consider adding probiotic
45
Q

Trauma Surgical Patient Consideration

A
  • Early enteral feedings with high protein polymeric diet initiated within 24-48 hours of injury once stable
  • Consider immune-modulating formulas with arginine and fish oil in severe trauma patients
46
Q

Traumatic Brain Injury Considerations

A
  • Similar to other critically ill patients, initiate early EN within 24-48 hours once stable
  • Consider using arginine-containing immune-modulating formulas or EPA/DHA supplement with standard EN formula (may accelerate recovery)
47
Q

Open Abdomen Considerations

A
  • OA technique, used to manage abdominal contents after damage control laparotomy
  • May have OA for days to weeks post-op
  • Very pro-inflammatory state
  • Initiate early EN 24-48 hours post-op in patients with OA in absence of bowel injury
  • Consider adding additional 15-30 g of protein per L of exudate loss for OA patients
48
Q

Burns Consideration

A
  • EN should be given to those with functioning GI and inadequate PO intake
  • Use IC when available to assess energy needs and repeat weekly
  • Initiate very early EN - within 4-6 hours of injury if possible
  • Protein goal: 1.5-2 g/kg
49
Q

Severe Sepsis/Septic Shock Considerations

A
  • EN within 24-48 hours of diagnosis, as soon as resuscitation is complete and stable
  • Not recommended to use exclusive PN or supplemental PN in conjunction with EN in acute phase
50
Q

Post-op Major Surgery Considerations

A
  • Determine nutrition risks on all post-of patients in ICU
  • Suggest initiating EN when feasible in post-op period within 24 hours of surgery
  • Suggest routine use of immune-modulating formula (arginine and fish oils) in SICU for post-ops
51
Q

Chronically Critically Ill Considerations

A
  • Persistent organ dysfunction requiring ICU stay of >21 days
  • Persistent inflammation, immunosuppression, and catabolism syndrome
  • Manage patients with aggressive high-protein EN therapy (also resistance exercise program when possible)
52
Q

Obesity in Critical Illness Patients Differences

A
  • More likely to have fuel utilization issues (greater loss of LBM)
  • Greater risk of insulin resistance
  • Get higher percentage of energy needs from protein metabolism
  • More complication than others with normal BMI: infection, longer stays, more organ failure, longer mechanical ventilation durations
53
Q

Obesity in ICU Considerations

A
  • EN within 24-48 hours of admission if PO intake can’t be sustained
  • High-protein hypocaloric EN to preserve LBM, mobilize adipose tissues, and minimize metabolic complications from overfeeding
  • Give supplemental thiamine prior to starting dextrose-containing fluids if history of bariatric surgery
  • Evaluate and treat for micronutrient deficiencies in bariatric surgery patients as well

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